That's the question that residents and educators have been asking themselves since last November, when the National Labor Relations Board (NLRB) ruled that residents are employees, not students. The board ruled that residents at Boston Medical Center—and everywhere else—have the same rights as other workers, including the right to unionize.

For years, training programs and residents have debated whether residents are students or employees. While housestaff at some public institutions have been allowed to unionize for years, the NLRB decision now gives that same option to the rest of the resident work force in private institutions.

While many residents welcomed the ruling, it also raised serious questions for housestaff and educators: Are enough residents so unhappy with their working environment that they will flock to unions? If that happens, will training programs be forced to change the way they treat residents? And how will union rules affect the learning environment?

Finding a voice

Talk to residents who have joined unions, and they say that they were looking for more of a voice in improving both working conditions and patient care. Housestaff unions, which have been around since the late 1950s, say they've helped restrict the use of 80-hour-plus workweeks and on-call duty at night, as well as help establish special patient care funds that allow housestaff to improve facilities.

The largest and best known housestaff union is the Committee of Interns and Residents (CIR), which petitioned the NLRB to officially recognize its housestaff union at Boston Medical Center. After the ruling, residents at the medical center voted 177 to 1 to choose their CIR-affiliated house officers association as their collective bargaining agent.

'Our gravest concern is that the collective bargaining process and its aftermath could unduly interfere in the education process.'

--Sheldon Steinbach, JD, general counsel, American Council on Education

At Harvard's Cambridge Hospital, where there has been a CIR-affiliated union since 1993, residents have used money from the union's patient care fund to put rocking chairs in delivery rooms and buy better blood pressure cuffs. Second-year internal medicine resident Brian J. Green, ACP­ASIM Associate, said that the union has also improved residents' working conditions. "We negotiated a night float system that means we only have to sleep at the hospital one out of every six nights," he said.

And at Alameda County Medical Center in Oakland, Calif., collective bargaining got high marks after the California Association of Interns and Residents (CAIR) merged with CIR. "I'm really impressed with our ability to organize ourselves and have the institution deal with us professionally," said Marian Geyer, MD, a third-year internal medicine resident at Alameda County Medical Center and a CIR representative.

Dr. Geyer explained that because of the union's efforts, she and her colleagues recently received their first pay raise in seven years—a 9% increase over the next two years. They were also able to negotiate for more computers for housestaff and an allowance for books and continuing education. Dr. Geyer said she hoped to work next on reducing on-call duty.

Union supporters say that unions are a particularly useful tool to combat the corporate mentality that strives to provide medical care as cheaply as possible. "All house officers should be in unions," Dr. Green said. "They will give you a lot more voice in how patient care is managed."

Not for everyone

But not everyone is a believer. Several years ago, Gail Wehrli, MD, a pathology fellow at Los Angeles County's Southern California Medical Center, had the choice of joining a union at her institution. She turned it down.

Last year, however, a vote by the residents made union membership mandatory, and CIR membership does not please the sixth-year resident at all. A major sticking point is her $60 monthly dues. In Dr. Wehrli's opinion, the fee isn't used to improve her education. "And that is the reason I'm in the residency program."

Even ardent union supporters acknowledge that collective bargaining is not for everyone. "Whether or not residents organize will depend on their satisfaction with their overall teaching and learning environment," said Susan Hershberg Adelman, MD, president of Physicians for Responsible Negotiations (PRN), the AMA's recently formed negotiating organization for physicians.

She explained that because union negotiations typically center on working conditions, residents are likely to be drawn to unions when they have specific issues with their teaching hospital. For example, residents who are required to transport patients or do other jobs normally handled by ancillary staff may try to negotiate the hiring of more ancillary staff.

Andrew C. Yacht, ACP­ASIM Associate, who worked with CIR at the Boston Medical Center, gave a similar assessment of how to identify residents who can be helped by unions. "Look for situations in which you feel powerless and in which patient care is being compromised," he said. "Then decide whether you need more influence to control your environment."

Dr. Wehrli, however, pointed out that there are other ways for residents to make sure that their needs are being met. She pointed out that an ombudsman dedicated to residents—and able to explore issues the residents may not want to make public—may partially alleviate the need to unionize.

For example, if a resident reported sexual harassment by an attending to a union representative, the case would have to be investigated. An ombudsman, on the other hand, could suggest alternatives and help the resident decide whether or not to pursue an investigation.

Another alternative to unionizing is housestaff organizations, which have long been recognized as bargaining agents for interns and residents. There are about 50 of these organizations nationwide. Housestaff organizations can collectively bargain with hospital administrations on issues ranging from salary to call rooms, but their negotiations wouldn't be legally binding, as they are for unions.

Will education suffer?

Unions may also have a chilling effect on the relationship between educator and trainee by subjecting the learning environment to grievances and binding arbitration, educators say.

"We still believe that residents are students," said Association of American Medical Colleges (AAMC) spokesman John Parker, explaining that organization's disappointment with the NLRB ruling. Meanwhile, AAMC is educating its members about collective bargaining and alternatives for residents. "We believe there are grievance mechanisms in place that will reduce the need for unions," Mr. Parker said. "It's important that residents know about them."

Others worry that unions might start off negotiating pay and hours but then quickly get involved in other areas that affect learning. "Our gravest concern is that the collective bargaining process and its aftermath could unduly interfere in the education process," said Sheldon Steinbach, JD, general counsel for the American Council on Education, the umbrella organization that represents the country's 1,800 universities and colleges.

Union-based rules for discharging residents for poor performance, for example, could make evaluation criteria and individual cases negotiable, according to the Accreditation Council for Graduate Medical Education (ACGME), which is responsible for accrediting postgraduate medical training programs within the United States. ACGME also noted that transfers, work assignments and rotations could become subject to negotiation, which could affect education. In addition, unions could try to bring the contents of tests and the manner of testing to the bargaining table.

The strike issue

Perhaps the biggest fear, and one of the fiercest arguments against physician unions, is that residents might go on strike. While most physicians—even those who are pro-union—say they would never strike, critics of physician unions remain wary.

Organized medicine is adamantly opposed to the idea of seeing physicians walk a picket line. The College supports the idea of physicians collectively negotiating with health plans on quality-of-care issues, but only if patient interests are protected and physicians don't engage in strikes, slowdowns or any type of work stoppage. (See "The Council of Associates' position on residents and unions," for more on the College's position on residents and unions.)

Union supporters are always quick to point out that striking would be counterproductive. "We don't want or need the right to strike," said Jack Seddon, executive director of the Federation of Physicians and Dentists, a Tallahassee-based affiliate of the National Union of Hospital and Health Care Employees. "This isn't a battle with patients. Doctors won't abandon their patients and, furthermore, they still have to deal with their medical practice board. So it's highly unlikely to happen."

PRN, the AMA's new collective bargaining group, wants to help resident groups negotiate with hospitals before situations ever reach a breaking point. Its bylaws prohibit it from engaging in any strike that withholds essential medical services from patients.

"We feel we can carry such negotiations out in a cordial fashion," said Dr. Adelman, PRN's president. "We have no interest in stirring the pot. If residents are happy, we are happy. If residents have issues to address, we have the knowledge and interest to help."

Despite such promises, medical educators remain wary. Striking, after all, is a union's ultimate threat, and many educators find it hard to believe that it wouldn't be used in some form. A strike or work slowdown could negatively affect patient care, a hospital's shaky financial status, and—ultimately, they say—resident education. *

The Council of Associates' position on residents and unions

By Alex S. Niven, ACP­ASIM Associate

Do residents really need the right to unionize? From my perspective, the answer is yes and no.

These are turbulent times for academic medicine, with many institutions engaged in financial belt-tightening. While most academic medical centers act in the best interest of their trainees, some programs are putting cost-cutting ahead of education, risking patient safety and educational quality.

Residents want a supportive environment where they can learn and take care of patients. They want to be able to identify problems in their work environment and work with their institution to change them. While many residency programs already do this very well, the National Labor Relations Board ruling is for those that do not.

The College has given the issue of physician unions considerable thought. Last July, the College reaffirmed existing rules from the Resident Review Committee that require training programs to give residents a mechanism to address patient care and work concerns with administrators.

The College's Council of Associates has drafted a similar policy, which was also adopted by the College last summer. The Council's position says that teaching institutions should make a third-party mediator from academic or organized medicine available to intervene when residents and administrators simply cannot agree. This position is designed to allow residents to effectively address institutional concerns with minimal outside influence or disruption of the educational environment. It could also help resolve many problems before residents feel the need to turn to unions for help.

Although the ruling by the National Labor Relations Board produced more questions than answers, the long-term ramifications of this decision clearly hinge on how residents choose to exercise their new-found rights. The Council of Associates has launched a major initiative to provide residents with the information they need to make a well-informed decision. The choice, and the future, will be up to the residents and the institutions for which they work.

So you want to join a union...

Residents who favor collective bargaining representation have several choices ranging from long-standing unions to the newest organization from the AMA. Here is a short list of labor organizations for interns, residents and fellows:

Committee of Residents and Interns (an affiliate of the Service Employees International Union). It represents 10,000 interns, residents, and fellows in New York, New Jersey, Massachusetts, Florida, California and the District of Columbia. Information: 212-725-5500; Web: www.cirdocs.org/.

Internal medicine physicians are specialists who apply scientific
knowledge and clinical expertise to the diagnosis, treatment, and
compassionate care of adults across the spectrum from health to complex
illness. ACP Internist provides news and information for internists
about the practice of medicine and reports on the policies, products and
activities of ACP. All published material, which is covered by
copyright, represents the views of the contributor and does not reflect
the opinion of the American College of Physicians or any other
institution unless clearly stated.